Fields marked * are required.
Fields marked ** are required when further information is needed to support the preceding question.
Consent
Yes    No    Not required: young person 16+
Yes   No

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Referrer Details

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Child/Young Person & Parent/Carer's Details

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Is the child/young person experiencing difficulties in more than one of the following areas:

- Feeding and Swallowing or Special Dietary Needs
- Communication
- Participation in Daily Activities
- Movement and Physical Activity


Essex Children’s Targeted Services work throughout Southwest Essex and Thurrock to meet the needs of our children and their families. Our pathways are delivered through a Multi-Disciplinary Team approach that are led by Consultant Paediatricians and Clinical Leads.

Support is offered using a variety of tailored methods including virtual information pathways that empower families, online clinics, and face to face appointments which may take place in schools, clinic or at home. The clinicians involved and/or the locations and services offered may shift and change over time and is targeted to best meet the child/young person's needs.

The information your provide within the referral form allows the referral to be assessed with the most appropriate teams and services being involved. Please ensure that you have taken time to read service specific information to ensure the correct information is being included to support referral acceptance. Further information can be found on our website: https://www.nelft.nhs.uk/services-essex-childrens-integrated-therapies

Please state nature of difficulties providing an explanation of concerns. Highlight any risks you are aware of. Describe support/ interventions that have been attempted as part of a Universal level of Support. (e.g. Health Visitor, Nursery, School and others)

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What would you and/or the parent/carer like to happen as a result of this request for support

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Please provide diagnosis or disability where present

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Yes    No    Not Sure

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Yes    No    Not Sure

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Yes    No    Not Sure
Yes    No    Not Sure

Essex BBT Children's Community Service - ASD and ADHD Assessment

Led by Consultant Community Paediatricians, we provide a multi-disciplinary service to Children and Young People exhibiting a developmental delay or disorder of function affecting social communication, speech and language, attention, learning ability, emotion, sensory sensitivities, and/or self-control that unfolds as an individual develops and grows.

Referrals to this pathway can be made from other health or educational professionals. Please note that self-referrals will not be accepted. Requests for support will be accepted if there is an indication of difficulties that are secondary to a neurodevelopmental condition.

We do not diagnose ADHD below 6 years of age - Please refer to the Health Visiting service for a developmental screen and behavioural support in the first instance. We will be happy to receive a re-referral if the Health Visitor escalates concerns.

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The neonatal surveillance follow up clinic provides multidisciplinary (Occupational therapy, Physiotherapy and Community Paediatrician) early assessment and intervention for pre term and high risk babies.

Developmental problem or disorder    Born before 30 weeks    Born between 30+o weeks and term with additional risk factors
Brain lesion or neuroimaging (e.g. IVH or cystic PVL)    Grade II or III HIE    Neonatal bacteria meningitis    Herpes simplex encephalitis

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Supplementary Forms to be completed before submission for referral to Neonatal Surveillance Team

Additional Documents if available to support referral

If you would like to find out what happens to personal information held about you, please read our privacy policy for more information: https://www.nelft.nhs.uk/download.cfm?ver=1014

Our Physiotherapists lead the support we provide to children and young people experiencing difficulties with movement or their ability to engage in physical activities. These could be due to reasons such as neurodevelopmental disorders, neuro-motor conditions, developmental delays/disorders, or acquired injuries.

The team will focus on promoting the development of movement to support a child or young person to achieve their optimal function. Our aim is to empower the family and the child/young person to work towards individualised goals to achieve their fullest potential.

We provide assessment, advice and, where appropriate, therapy to support the development of independence using fun, positive activities and strategies.

Yes    No

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Yes    No    Not Sure

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0-6 weeks    Up to 3 months    Over 3 months

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Yes    No

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Our children’s feeding and dietetic service provides a specialist service for babies and children living within Basildon, Brentwood and Thurrock registered with a local GP.

We offer a high quality, coordinated service to support children and their families with a wide range of medical and developmental feeding difficulties and special dietary needs.

The multidisciplinary team consists of:

  • Paediatric Dietitians
  • Dysphagia Specialist Speech and Language Therapists
  • Children’s Occupational Therapist
  • Specialist Children’s Nurse
  • Experienced team Assistants
  • Team administrators

We work throughout Southwest Essex and Thurrock to meet the needs of our children and their families, using a variety of different methods including support from our virtual information resources hub, online clinics or face to face appointments in schools, clinics and at home depending on the child’s need. This includes single professional and multidisciplinary assessment, diagnosis, support and management.

Please visit to check our referral creteria: https://www.nelft.nhs.uk/our-referral-process

Yes    No    Not Sure

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Yes    No    Not Sure
During eating    After eating    During Drinking    After Drinking    Anytime    at night
Liquids    Puree    Lumpy foods    Finger foods    None of the above    Not sure
Yes    No    Not Sure

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Yes    No    Not Sure
Chest infection    Ear Infection    Throat Infection    Urine Infection    Other

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Yes    No
Nasogastric    Nasojejunal    Gastrostomy    Gastro-Jejunostomy
Yes    No    Not Sure
Roll    Sit Assisted    Sit Independently    Crawl    Stand    Walk    Jump
Lap    Bouncy seat    Car seat    Highchair    Chair    Special seating    No concerns    Not Sure
Underweight    Overweight    No concerns    Not Sure

Please explain why these programs have not been suitable?

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Yes    No    Not Sure
Known cows milk    Known soya    Known fish    Known egg    Known wheat    Known nuts    Known others    Suspected cows milk    Suspected soya    Suspected fish    Suspected egg    Suspected wheat    Suspected nuts    Suspected others

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Immediate    Delayed    Mixture

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Yes    No    Not Sure
Wet and Dry foods    Wet foods only    Dry foods only    None    Not Sure
Yes    No    Not Sure

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Please attach a report to support the referral if available

We provide specialist assessment and support to children with communication difficulties that are having a significant functional impact on the social, emotional and/or educational development of the child or young person. Led by our Speech and Language Therapists, the team works with parents, carers, early years' practitioners, schools and other healthcare professionals to create a supportive environment for the development of communication skills.

Speech, Language and Communication difficulties may include:

  • Difficulties understanding and/or using words or sentences
  • Speech sound difficulties making child hard to understand
  • Difficulties with social communication and social interaction
  • Communication that needs to be supported using alternative or augmentative communication
  • Stammering
  • Communication difficulties as part of deafness

Yes    No

We expect that initial support would have been put in place by the school and that a referral is only made if there is evidence that good quality school provision is not sufficient to meet the child/young person's needs. We will not be able to provide appropriate intervention without this level of support already being in place and the referral will be rejected unless the SENCO has previously discussed this referral with the link Speech and Language Therapist for the school.

A referral is not needed. Please contact our drop-in team at drop-in@nelft.nhs.uk for sessions which are held regularly across the area. You will not need to complete the rest of this referral form.

Yes    No

We expect that initial support would have been put in place by the school and that a referral is only made if there is evidence that good quality school provision is not sufficient to meet the child/young person's needs. We will not be able to provide appropriate speech, language and communication intervention without this level of support already being in place and the referral may be rejected on these grounds.

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Yes    No    Not Sure

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Always in all situations    Sometimes at school    Unfamiliar people find it hard to understand them    Never
Yes    No    Not Sure

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Repeating sounds (c c c can I ……)    Repeating words (can can can I ……)    Repeating phrases (can I … can I … can I…)    Does he get stuck on a sound (blocking)?    Does he elongate a sound?
Yes    No

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Yes    No

We work with children experiencing a variety of difficulties that affect their ability to participate in daily activities (Occupations) at home and/or school. These could be due to physical, developmental, sensory or neurological impairment, or as a result of illness or trauma.

Our Occupational Therapists lead the support we provide to children who are experiencing these difficulties with the aim to improve their health, independence and wellbeing.

Activities of Daily Living may include:

  • Self-care (dressing, eating a meal, using the toilet)
  • Being productive (participating in activities/routines at home or school)
  • Leisure (Playing with friends, doing sports or hobbies)
We provide assessment, advice and, where appropriate, therapy to support the development of independence using fun, positive activities and strategies.

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Home    School
Yes    No

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Should you wish to send additional documents or in another format, please do so separately, including the child's name and DOB to: CSPA@nelft.nhs.uk

Autism and ADHD Pre-Assessment Information to be completed by the Parent/ Carer

Referral Information for Autism and ADHD Assessment: Schools/ Pre-School use

School or nursery progress report
One Plan/Early Support Plan/Portage reports
Any other applicable reports
Educational Psychology report
Reports from therapists within school

Should you wish to send additional documents or in another format, please do so separately, including the child's name and DOB to: asdadhdcspa@nelft.nhs.uk

Movement & Coordination Pathway

Neonatal Pathway

Acute Musculoskeletal Pathway

Speech Language Pathway

Looking After Pathway

Healthcare Pathway

What happens to your information?
If you would like to find out what happens to personal information held about you, please read our privacy policy for more information:
https://www.nelft.nhs.uk/download.cfm?ver=1014